1518943968 NPI number — FREEDOM 2 GO LLC

Table of content: (NPI 1518943968)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518943968 NPI number — FREEDOM 2 GO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FREEDOM 2 GO LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518943968
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2802
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ABILENE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79604-2802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
325-437-2382
Provider Business Mailing Address Fax Number:
325-437-2388

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
401 TEMPLE HALL HWY STE 5
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANBURY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76049-8104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-573-6842
Provider Business Practice Location Address Fax Number:
817-573-6858
Provider Enumeration Date:
12/19/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LAMB
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
325-437-2382

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 176767501 . This is a "CCP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 176767502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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